Summer Enrichment

2023 Summer Enrichment Registration Form

* Child's Name

* 2023/2024 Grade Level

* Child's Birth Date

* Child's Age

* Child's Gender

Male Female

* Father's Name

* Father's Home Phone Number

* Father's Work Number

* Father's Cell Phone

* Mother's Name

* Mother's Home Phone Number

* Mother's Work Number

* Mother's Cell Phone

* Alternate's Name

* Alternate Home Phone Number

* Alternate's Work Number

* Alternate's Cell Phone

* Address

* City

* State

* Zip Code

* Email

I give permission for the Director and/or Staff to take the above mentioned child to the hospital for medical treatment

in case of an accident or illness, and to receive medication(s) prescribed by the attending physician(s):

* Signature (Please type name of parent/guardian giving permission)

* Doctor's Name

* Doctor's Phone Number

* Insurance Name

* Insurance Group No.

* Insurance Company Phone Number

* Does this child have any allergies, drugs or otherwise? If yes, please list:

* Does this child have any chronic illness? If yes, please list:

* Has this child had surgery within the last year? If yes, please list:

* Is this child taking any medication(s)? If yes, please list:

* Has this child had a Tetanus shot within the last six months?

I give for the afore-mentioned child to participate in all activities, including water activities, during the Fifth Ward Church of Christ 2023 Summer Enrichment Program.

* Signature (Please type name of parent/guardian giving permission)

*** You must have JavaScript enabled to use this form ***